Kittson Healthcare

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain a safe environment by ensuring appropriate precautions remained in place while a freshly mopped floor was wet for 1 of 2 residents (R25) reviewed for falls and failed to provide transfer assistance in accordance with the resident's care-planned interventions for 1 of 1 resident (R9) reviewed for transfer assistance. This resulted in actual harm for R25 when she slipped and fell on the freshly mopped, wet floor, struck her head on the concrete floor, and sustained a head laceration that required emergency medical evaluation and staples.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact resident care activities, f1 of 1 resident (R18) reviewed for catheters and 1 of 1 resident (R29) reviewed who was receiving wound care. In addition, the facility failed to conduct ongoing infection surveillance to identify and track residents with signs and symptoms of potential infection for 1 of 1 resident (R1) reviewed for infection surveillance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess ability to independently activate the call light and provide a reasonable accommodation for 1 of 1 resident (R29), such as an adaptive call light, after staff became aware of ongoing difficulty using the standard call system, resulting in the potential for delayed access to assistance for toileting and other care needs.

Inspectors wroteBased on interview and document review, the facility failed to ensure an as-needed (PRN) antipsychotic medication order was limited to 14 days and failed to ensure the resident was evaluated by the prescribing practitioner before the PRN antipsychotic medication was renewed. In addition, the facility failed to ensure there was adequate clinical justification for the use of the PRN antipsychotic medication when it was restarted at the request of the resident's family for 1 of 5 residents (R19) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to identify and report an alleged violation of neglect to the State Agency (SA) for 1 of 1 resident (R25) reviewed for accident reporting. R25 slipped and fell on a freshly mopped, wet floor after facility staff failed to place a wet-floor warning sign and sustained a head laceration that required six sutures at the emergency department. R25's annual Minimum Data Set (MDS) dated [DATE], identified R25 had intact cognition, was independent with activities of daily living (ADLs), transfers and ambulation. R25 had not experienced any falls since admission or the previous assessment. Diagnoses included repeated falls, dysthymic disorder, unspecified intracranial injury, osteoporosis, essential tremor, paroxysmal vertigo, gait and mobility abnormalities, weakness, urinary incontinence, seizures and disorientation. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to revise the comprehensive care plan to accurately reflect that a resident was independent with toileting, transfers, and ambulation for 1 of 4 residents (R15) whose care plans were reviewed. Findings Include:R15's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment. R15 needed supervision to touch assist with toileting, transfers, and walking. Diagnosis included Alzheimer's disease-late onset. No falls from the last assessment (3 months). R15's care plan dated 5/21/26, identified R15 had a history of fallsAn intervention dated 5/21/26, identified per therapy R15 was observed with an unsteady balance and was not able to stabilize without human assistance for on and off the toilet and surface-to-surface transfers; independent with standing, walking, turning around while walking. [...]

Inspectors wroteBased on interview and document review, the facility failed to provide timely toileting assistance for 1 of 1 resident (R13) reviewed who had complaints of not receiving timely toileting assistance.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with incontinence care for 1 of 1 resident (R9) reviewed for activities of daily living and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to reposition a resident in accordance with the resident's established every two-hour turn and reposition schedule for 1 of 1 resident (R9) reviewed for pressure ulcer prevention and was at risk for developing pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a comprehensive assessment was completed related to a diagnosis of Post Traumatic Stress Disorder (PTSD) to identify and mitigate potential triggers for 1 of 2 residents (R1) reviewed for trauma-informed care.

Inspectors wroteBased on interview and document review, the facility failed to obtain laboratory services as ordered for 1 of 1 resident (R9) reviewed for laboratory services when staff failed to arrange a white blood count (WBC) laboratory draw ordered for 7/10/26 following R9's return from the emergency department (ED).

Inspectors wroteBased on interview and document review, the facility failed to implement its antibiotic stewardship protocols for the assessment and monitoring of antibiotic use for 1 of 2 residents (R9) reviewed for antibiotic use. R9 received repeated courses of antibiotics for suspected urinary tract infections (UTIs); however, the facility failed to use its established UTI assessment process and failed to complete, and document required 72-hour antibiotic reassessments to evaluate the continued need, duration, and selection of antibiotic therapy.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a transfer belt was used during a transfer for 1 of 2 residents (R30) reviewed for falls. This resulted in actual harm to R30 who sustained a left arm fracture. The facility implemented corrective action prior to the survey; therefore, the deficient practice was issued at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to ensure there was a signed copy an advanced directive (identifying whether to do cardiopulmonary resuscitation (CPR) or do not resuscitate (DNR)) for 1 of 16 resident (R31) reviewed for advanced directives.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents with attached bed rails were comprehensively assessed for use on the bed for 1 of 1 resident (R4) who had bed rails.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure medications were administered according to manufacturers instructions for 1 of 1 residents (R31) observed during medication administration.

Inspectors wroteBased on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits for vaccinations being offered along with offering the most recent pneumococcal vaccine for 3 of 5 residents (R24, R28, R31) reviewed for immunizations.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the daily census was on the nurse staff posting. This had the potential to affect all 31 residents residing in the facility and/or visitors who may wish to view the information.

Inspectors wroteBased on observation, interview and document review, the facility failed to implement timely transmission-based precautions (TBP) and testing for COVID-19 according to the Centers for Disease Control (CDC) for 4 of 4 residents (R31, R1, R12, R30) who were displaying COVID-19 symptoms; and failed to ensure enhanced barrier precautions (EBP) were implemented for an indwelling catheter for 1 of 1 resident (R38) reviewed for catheter care.

Inspectors wroteBased on interview and document review the facility failed to ensure unlicensed personnel did not administer injectable medications consistent with state requirements for 4 of 4 residents (R25, R28, R31, R35 ) who received insulin injections; and the facility failed to ensure medications were administered as ordered for 3 of 3 (R3, R16, R21) residents whose medications were omitted during medication pass and medication remained in the pharmacy return medication.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure prescription eye drops were dated when opened to ensure expired product was not administered for 3 of 3 residents (R13, R23, R38) on 1 of 2 medication carts reviewed for medication storage.

Inspectors wroteBased on interview and document review, the facility failed to implement antibiotic stewardship protocols for 1 of 3 residents (R4) identified to have been taking an antibiotic. This had the potential to affect all 36 residents who were or may receive antibiotic therapy in the future.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were protected from exposure for 1 of 3 residents (R19) observed exposed from the hallway.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were free from physical restraints for 1 of 2 residents (R13) reviewed for restraints.

Inspectors wroteBased on observation, interview and document review, the facility failed to report an allegation of rough treatment and restraining a resident for 1 of 2 residents (R13); and the facility failed to report an injury of unknown origin for 1 of 2 residents (R4) reviewed for potential abuse.

Inspectors wroteBased on observation, interview and document review, the facility failed to complete a thorough investigation related to an allegation of rough treatment and restraining a resident for 1 of 2 residents (R13); and the facility failed to report an injury of unknown origin for 1 of 2 residents (R4) reviewed for potential abuse.

Inspectors wroteBased on observation, interview and document review, the facility failed to identify, comprehensively assess, develop and/or implement appropriate interventions in order to promote skin integrity and healing of skin tear on the scrotum for 1 of 1 resident (R4).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure interventions for preventing pressure ulcers were implemented for 1 of 2 residents (R10) reviewed who was at risk for the development of pressure ulcers.

Inspectors wroteBased on observations, interview and document review the facility failed to ensure safe resident transfer practices were consistently followed for 1 of 1 residents (R13) reviewed for accidents; and the facility failed to provide a safe environment and supervision for 1 of 3 (R19) residents reviewed for wandering.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure care planned dementia care interventions were provided for 1 of 1 resident (R16) reviewed for dementia care.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents received treatment and services, in accordance with professional standards of quality, when 1 of 1 resident's (R1) physician-prescribed medication taper order was not implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were monitored for target behaviors, monitored for side effects, and educated on the risks/benefits of psychotropic use prior to initiation for 1 of 3 residents (R1) reviewed for unnecessary medications. This deficient practice caused actual harm when R1 experienced a decline in condition following the initiation and continued increase of a psychotropic medication.

Inspectors wroteBased on interview and document review the facility failed to inform a responsible party in advance of the risks/benefits and receive informed consent of proposed care for 1 of 3 residents (R1) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the consultant pharmacists recommendations were addressed for 1 of 3 residents (R1) reviewed for unnecessary medication.